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PubMed1985

An analysis of the magnitude of clinical-reasoning deficiencies in one class.

Clinical-reasoning ability is indispensable to a good doctor, but students are generally expected to "pick it up" in the course of their clinical clerkships. Concern by the University of Washington School of Medicine that some students did not master the concepts of clinical reasoning led to the formation of an ad hoc committee whose retrospective study on the class of 1981 is reported here by the authors. Nineteen students (11 percent of the graduating class) who were repeatedly noted by faculty members to have problems with clinical reasoning throughout their clinical clerkships were identified as a result of this study.

Achievement↗
PubMed1989

The effect of teaching medical ethics on medical students' moral reasoning.

A study assessed the effect of incorporating medical ethics into the medical curriculum and the relative effects of two methods of implementing that curriculum, namely, lecture and case-study discussions. Results indicate a statistically significant increase (p less than or equal to .0001) in the level of moral reasoning of students exposed to the medical ethics course, regardless of format. Moreover, the unadjusted posttest scores indicated that the case-study method was significantly (p less than or equal to .03) more effective than the lecture method in increasing students' level of moral reasoning. When adjustment were made for the pretest scores, however, this difference was not statistically significant (p less than or equal to .18). Regression analysis by linear panel techniques revealed that age, gender, undergraduate grade-point average, and scores on the Medical College Admission Test were not related to the changes in moral-reasoning scores. All of the variance that could be explained was due to the students' being in one of the two experimental groups. In comparison with the control group, the change associated with each experimental format was statistically significant (lecture, p less than or equal to .004; case study, p less than or equal to .0001). Various explanations for these findings and their implications are given.

Control Groups↗
PubMed1996

Teaching clinical reasoning to second-year medical students.

In most U.S. medical schools, students begin clinical clerkships during their third year. They are expected to arrive prepared with the skills necessary to participate in patient-care activities, including data gathering, care coordination, and diagnostic reasoning. However, most students' training may inadequately prepare them to be proficient in diagnostic reasoning, and little time is available in the third year to develop these skills. Because of this inadequate preparation, students may become frustrated with many aspects of their clerkships. This paper describes a series of exercises developed by the author and implemented in this three years as a clinical tutor for second-year medical students in an introduction to clinical medicine course. The exercises are designed to accelerate the student's understanding of diagnostic reasoning, thereby better preparing them for the requirements of the third-year clerkship. The author describes how he uses this teaching approach and discusses in detail the method's central components. He notes that the six students he has worked with from 1993 to the present have responded very positively, and that further research is needed to explore possible long-term benefits of this teaching method.

Clinical Clerkship↗
PubMed2001

Alternative medicine and common errors of reasoning.

Why do so many otherwise intelligent patients and therapists pay considerable sums for products and therapies of alternative medicine, even though most of these either are known to be useless or dangerous or have not been subjected to rigorous scientific testing? The author proposes a number of reasons this occurs: (1) Social and cultural reasons (e.g., many citizens' inability to make an informed choice about a health care product; anti-scientific attitudes meshed with New Age mysticism; vigorous marketing and extravagant claims; dislike of the delivery of scientific biomedicine; belief in the superiority of "natural" products); (2) psychological reasons (e.g., the will to believe; logical errors of judgment; wishful thinking, and "demand characteristics"); (3) the illusion that an ineffective therapy works, when actually other factors were at work (e.g., the natural course or cyclic nature of the disease; the placebo effect; spontaneous remission; misdiagnosis). The author concludes by acknowledging that when people become sick, any promise of a cure is beguiling. But he cautions potential clients of alternative treatments to be suspicious if those treatments are not supported by reliable scientific research (criteria are listed), if the "evidence" for a treatment's worth consists of anecdotes, testimonials, or self-published literature, and if the practitioner has a pseudoscientific or conspiracy-laden approach, or promotes cures that sound "too good to be true."

Cognitive Dissonance↗
PubMed2003

From case-based reasoning to problem-based learning.

Many medical schools today are questioning whether they should implement a problem-based learning (PBL) curriculum. Educators have raised serious questions regarding the efficiency of PBL and therefore recommend learning more about the cognitive processes developed by PBL before implementing it broadly. In addition, it is important to determine whether PBL best matches the human reasoning process. The authors' theoretical discussion examines the relationship between the case-based reasoning (CBR) model and the PBL model. CBR indicates that the knowledge source one uses while solving a new problem includes not only generalized rules or general cases, but often a memory of stored cases recording specific prior episodes. CBR enables the reasoner to recommend solutions to problems quickly and to propose solutions in domains that are not completely understood, such as medicine. The authors' analysis reveals a strong association between the CBR and PBL models, and thus it can be argued that PBL is a successful teaching method that should be encouraged by medical schools.

Curriculum↗
PubMed1994

Case-based reasoning and imaging procedure selection.

RATIONALE AND OBJECTIVES: Case-based reasoning, an artificial intelligence technique for learning and reasoning from experience, has shown great potential for use in decision support systems. The authors developed and tested a prototype case-based decision support system to explore the applicability of this technique to the selection of diagnostic imaging procedures. METHODS: A case-based system, ProtoISIS, was developed based on the Protos learning apprentice. ProtoISIS learned the domain of ultrasonography and body computed tomography by reviewing 200 consecutive cases of actual requests for imaging procedures. ProtoISIS was tested by using it to classify four sets of 25 cases of actual imaging procedure requests. RESULTS: ProtoISIS correctly classified 72% of the imaging-procedure requests. Its performance improved as it gained experience: in the last two test series, it correctly classified 84% of the cases presented. CONCLUSIONS: Case-based reasoning can be applied successfully to the selection of diagnostic imaging procedures and holds potential for use in clinical decision support aids. Further work is necessary to realize a clinically useful system.

Artificial Intelligence↗
PubMedDate not supplied

Friday night in the pediatric emergency department: a simulated exercise to promote clinical reasoning in the classroom.

High acuity in client populations has placed increasing demands on novice nurses to apply concepts of clinical reasoning to nursing practice. To assist nursing students in developing clinical reasoning skills, an exercise called "Friday Night in the Pediatric Emergency Department" was designed to give students real-time experiences in triage situations using a simulated clinical experience in a classroom setting. The author describes the exercise and its impact on the clinical reasoning skills of undergraduate nursing students.

Attitude of Health Personnel↗
PubMed2000

The fate of liver grafts declined for subjective reasons and transplanted out of a local organ procurement organization.

BACKGROUND: Decisions made by transplant surgeons to decline liver grafts for local use are based on both objective and ill-defined subjective parameters. These livers may be offered and subsequently transplanted at non-local centers. We analyzed the fate of these exported livers, focusing on the outcome of grafts declined for subjective reasons. The aim is to determine whether local surgeons' concerns about inferior graft function are justified. METHODS: Over a 3-year period, 13.3% of 555 livers in our organ procurement organization (OPO) were exported and transplanted out of the local area. Donor data and reason for decline were obtained from an extensive OPO database. Objective reasons for decline were based on no appropriate matched recipient due to donor size, serologies, or malignancy with potential for spread. Subjective parameters were related to the procuring surgeon's assessment and included variables such as medical and social history, abnormal liver enzymes, older age, organ visualization, and biopsy. Recipient data were obtained from questionnaires sent to outside transplant centers. RESULTS: There was a significantly higher rate of nonfunction in the subjective group (17.1%), compared to the objective group (0%). One-year graft and patient survival were 79 and 83% for the objective group and 59 and 68% for the subjective group (P=NS). When donors declined for medical/social history were excluded from the subjective group, leaving only grafts declined based solely on the surgeon's assessment of graft quality, there is a significant difference in graft survival (79% for objective and 46% for this subjective subgroup, P=0.03). CONCLUSIONS: Livers declined for local use based on subjective assessment by the procuring surgeon have a high nonfunction rate, associated with a high morbidity. Therefore, the use of these grafts should be restricted to recipients at the most urgent status.

Adolescent↗
PubMed1997

Diagnostic reasoning in acute and critical care.

Diagnostic reasoning is a dynamic thinking process that leads to the identification of a hypothesis that best explains the clinical evidence. Nurses in advanced practice today frequently diagnose the origin of medical and nursing problems that develop in acutely and critically ill adults. Inherent in the specialty fields of acute and critical care are unique factors that can affect the quality of diagnostic reasoning and can potentially complicate the process. An understanding of the basic principles underpinning diagnostic reasoning and the associated common errors is essential for clinicians and students to improve their diagnostic skills.

Acute Disease↗
PubMed2001

Integrating clinical reasoning and evidence-based practice.

Evidence-based practice involves basing clinical decisions and practice on the best available evidence. What do nurses need to think about when seeking to pursue evidence-based practice? What challenges do practitioners face in blending clinical reasoning with evidence-based practice? In this article, the authors argue against basing clinical practice on narrow definitions of evidence, relying solely on experimental findings or, even more exclusively, on randomized controlled trials. Instead of defining best practice narrowly by the strength of the current empirical evidence used to guide clinical decisions, it should be defined broadly by what is the best information to use to make decisions for a given patient in a particular setting. Credible and accountable clinical decisions rely on a number of forms of knowledge and evidence. This evidence includes findings from across the range of research methods, including experimental, interpretive, and action research. In nursing, it also includes evidence that has arisen from the depth of practice knowledge of expert clinical nurses. Professionals, particularly advanced and expert clinicians such as critical care nurses, use clinical reasoning to guide their practice in the uncertainty of clinical practice contexts. This reasoning helps the nurse make judgments about the relevance of particular research and clinical evidence for a specific patient and setting.

Decision Making↗
PubMed2004

Reasons for revision hip surgery: a retrospective review.

The purpose of this study was to determine the indications for contemporary revision hip surgery in a consecutive series of patients. We retrospectively reviewed the clinical records and radiographs of 439 revision hip surgeries done between 1996 and 2003. Fifty-five percent of the surgeries were for aseptic loosening, 14% were for instability, 13% were for osteolysis around a well-fixed implant, 7% were for infection, 5% were for periprosthetic fracture, 3% were for conversion of a hemiarthroplasty, 1% was for psoas impingement, 1% was for loose recalled implants, and 1% was for implant fracture. As expected, aseptic loosening was the most common reason for revision surgery. Instability was a common reason for early revision whereas revision for osteolysis around a well-fixed implant was a more common reason for late revision.

Adult↗
PubMed2006

Implant recommendation as a replacement option after tooth loss for periodontal reasons.

PURPOSE: The aim of this study was to examine the frequency of implant recommendation by general dental practitioners to patients who had extractions as a result of periodontal disease and factors that influenced their decisions. MATERIALS AND METHODS: Dentists in each of 20 general dental practice centers in Kuwait were asked to document replacement options given to patients after all tooth extractions performed for periodontal reasons within a 30-day period. The association of demographic and medical/dental history variables with the decision to recommend an implant was statistically tested. RESULTS: A total of 711 patients with a mean age +/- of 47.34 +/- 0.45 years (range 18-96) had 2202 teeth extracted for periodontal reasons during the study period. Only 21 implants for 12 patients were offered as a replacement option (1.7%). Factors significantly associated with a less likelihood of implant recommendation included older age, male gender, diabetes mellitus, inadequate compliance with regular periodontal maintenance visits, inadequate oral hygiene practices, and anterior tooth types (P < 0.05; chi test). CONCLUSION: Dental implants were rarely recommended to patients losing their teeth for periodontal reasons by general dentists in Kuwait.

Adolescent↗
PubMed2004

Adolescent psychiatric inpatients' self-reported reasons for cutting themselves.

To ascertain (1) whether male and female adolescent (13-17 years old) psychiatric inpatients endorse comparable reasons for cutting themselves and (2) whether these reasons are correlated with selected psychosocial characteristics of the adolescents, self-reported depression, and hopelessness, the Self-Injury Motivation Scale II (SIMS-II), the Beck Depression Inventory-II, and the Beck Hopelessness Scale were administered to 19 (38%) male and 31 (62%) female adolescents who had cut themselves. Independent t tests found that none of the SIMS-II subscale scores was differentiated by sex, but the Beck Depression Inventory-II total score was significantly correlated with the SIMS-II total, Affect Modulation, Desolation, and Punitive Duality subscale scores. The results are discussed as indicating that male and female adolescent inpatients endorse comparable reasons for cutting themselves and that self-reported depression is positively associated with the number and intensity of different motivations for cutting oneself.

Adolescent↗
PubMed2004

A cognitive neuroscience framework for understanding causal reasoning and the law.

Over the past couple of decades, there have been great developments in the fields of psychology and cognitive neuroscience that have allowed the advancement of our understanding of how people make judgements about causality in several domains. We provide a review of some of the contemporary psychological models of causal thinking that are directly relevant to legal reasoning. In addition, we cover some exciting new research using advanced neuroimaging techniques that have helped to uncover the underlying neural signatures of complex causal reasoning. Through the use of functional imaging, we provide a first-hand look at how the brain responds to evidence that is either consistent or inconsistent with one's beliefs and expectations. Based on the data covered in this review, we propose some ideas for how the effectiveness of causal reasoning, especially as it pertains to legal decision-making, may be facilitated.

Brain↗
PubMed2005

An improved robust fuzzy-PID controller with optimal fuzzy reasoning.

Many fuzzy control schemes used in industrial practice today are based on some simplified fuzzy reasoning methods, which are simple but at the expense of losing robustness, missing fuzzy characteristics, and having inconsistent inference. The concept of optimal fuzzy reasoning is introduced in this paper to overcome these shortcomings. The main advantage is that an integration of the optimal fuzzy reasoning with a PID control structure will generate a new type of fuzzy-PID control schemes with inherent optimal-tuning features for both local optimal performance and global tracking robustness. This new fuzzy-PID controller is then analyzed quantitatively and compared with other existing fuzzy-PID control methods. Both analytical and numerical studies clearly show the improved robustness of the new fuzzy-PID controller.

Algorithms↗
PubMed1997

Genetic therapy, person-regarding reasons and the determination of identity.

It has been argued, for example by Ingmar Persson, that genetic therapy performed on a conceptus does not alter the identity of the person that develops from it, even if we are essentially persons. If this claim is true then there can be person-regarding reasons for performing genetic therapy on a conceptus. Here it is argued that such person-regarding reasons obtain only if we are not essentially persons but essentially animals. This conclusion requires the defeat of the origination theory, which says that personal identity is determined by the identity of the foetus from which one originates. It is argued that the origination theory is false in the special case relevant to performing genetic therapy on a conceptus for person-regarding reasons.

Altruism↗
PubMed1999

Desire-based and value-based normative reasons.

This paper is a response to John Harris' provocative 'Justice and Equal Opportunities in Health Care'. The aim of this short response is to locate the difference between Harris and me within a broader debate about the nature of reasons for action. I argue that Harris is appealing to a desire-based conception of normative reasons. I highlight some of the deficiencies of a desire-based conception of reasons, and contrast it with a value-based account.

Delivery of Health Care↗
PubMedDate not supplied

The development of reasoning about the teaching of values in school and family contexts.

This study investigated children's, adolescents', and young adults' reasoning about the teaching of a variety of values in the school and family contexts. One-hundred and sixty participants in four age groups (8-, 10-, and 13-year-olds, and college students) evaluated acts involving the teaching of values and laws that regulate the teaching of these values. Both the valence (positive or negative) of values and the context in which they were presented (school, family) were systematically varied. Results showed that a variety of factors were considered in evaluating the teaching of values, including context, the valence of the value, and the type of value being taught. Participants' reasoning about values education was found to be multifaceted and included distinctions between moral values that reflect justice and rights, and values that reflect other forms of personality traits and social values. The findings suggest that conceptions of values education may be better understood within models of social reasoning that draw distinctions between types of values (e.g., moral and other values) and account for the increasing capacity to differentiate social contexts and spheres of legitimate governmental regulation with development.

Adolescent↗